Monday, May 6, 2002
The Vancouver Sun

Operating in the Dark – AGAIN AND AGAIN

By Dr. David Zitner

You wouldn’t want a blindfolded surgeon to operate on you in a poorly lit operating theatre. Yet that is what we regularly permit our politicians to do to the health care system. Health care is the largest public spending program in government. Yet we do not possess the information that would allow us to assess the performance of the current system, let alone evaluate the realistic alternatives. Policy makers and health administrators are operating in the dark.

Premier Gordon Campbell of British Columbia is only the most recent Canadian politician to implement major changes in health services delivery without providing anyone with an estimate of how these changes will effect waiting time, health care results, or how in one or two years British Columbians will know if the new systems are better or worse than the old. He too is just operating in the dark.

No health jurisdiction in Canada systematically tracks those people who are on waiting lists for care or tracks what happens to those who wait. We know little about the outcomes of care. Appliance sellers and auto repair shops routinely canvass people to learn about satisfaction and results. Not so for health care. When were you last called to find out if you were better or worse following either hospital treatment or a medical office visit?

This lack of vital information about access to care and the results of care makes it impossible for Canadian health care administrators to learn from their own mistakes and successes. The failure to learn from mistakes is one reason that most Canadians believe that changes to health services delivery are more likely to make care worse, not better.

Yet Canadians spend large amounts to gather and collect information to support health care. The Canadian Institute for Health Information (CIHI) receives $95,000,000 from Ottawa and produces several information products. Each province sends CIHI (in Ottawa and Toronto) information about each of your admissions to hospital, the diagnoses which caused your condition, what procedures were done, and how long you were in hospital. Even with this detailed review, of each page, of each chart, by a hospital employee, no one has bothered to ask how long did you wait for care?, or did you get better or worse? And yes, the provinces together spend substantially more than $95,000,000 to support this enterprise since the cost of gathering hospital data in a single 400-500 bed hospital is about $1,500,000.

Technical notes, produced by the CIHI, clearly state that even this limited information is not reliable. CIHI provides the following warning “these data have been used extensively in previous reports on health care performance and form the basis for many journal articles. However, the data are not always accurate”. Nobody really knows when the data are accurate or inaccurate. Would you have any confidence in a pilot, flying in the fog, who reported that his compass and altimeter worked some of the time?

Canadian policy makers are blithely undeterred by the lack of tools to guide health services administration. The Senate Committee on Health Care led by Senator Michael Kirby, drawing on a paper I co-authored (“Public Health, State Secret”), identifies the reason.

Health care in Canada functions as an unregulated monopoly because the regulator (government) is the monopoly provider of insured health services. Organizations, even well-intentioned ones, develop strategies for self preservation and so there is an incentive to avoid collecting critical information.

My colleague Brian Lee Crowley, President of the Atlantic Institute for Market Studies commented to the Romanow commission that “Governments are not fulfilling their role as a health system regulator because governments are being asked to evaluate and regulate themselves.”

In 1994 the Federal/Provincial/Territorial Deputy Ministers of Health unanimously agreed that “Timely access to services must be guaranteed and information about waiting time made public”. Accessibility is one of the prime principles of the Canada Health Act, and a principle dear to the heart and health of all Canadians. The Deputies also agreed that “Quality of care will be ensured by ongoing monitoring and publication of patient outcomes as changes are implemented.”

Unfortunately, Canadian governments have concentrated on the Canada Health Act principle vital to their self-preservation: public administration. Governments have largely ignored the development of compliance standards for the other 4 principles, which are the ones most important to patients: accessibility (waiting times are often unconscionably long); comprehensiveness (many services are not covered); portability (the menu of covered services differs from province to province); and universality (not everyone is covered in the same way-for example workers compensation patients have preferred access in several provinces)

One solution, proposed in “Public Health, State Secret and supported by Mr. Kirby is “to separate the functions of health care financing, delivery, and evaluation in order to increase efficiency of health care delivery. This is necessary to make the system more transparent and accountable by providing more accurate and objective evidence-based information about access, outcomes and costs than is now available. This separation will also help make the system more patient-oriented than it is now”. When we have appropriate information, governments will be able to set standards to ensure that Canadians get appropriate care delivered by either the public or private sector.

Dr. David Zitner is Director of Medical Informatics at Dalhousie University Medical School and the Atlantic Institute for Market Studies (AIMS) Fellow in Health Policy.